Provider Demographics
NPI:1245224302
Name:BUB, IVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:
Last Name:BUB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 KEISER BLVD
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-3333
Mailing Address - Country:US
Mailing Address - Phone:610-775-3316
Mailing Address - Fax:610-796-2962
Practice Address - Street 1:2610 KEISER BLVD
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-3333
Practice Address - Country:US
Practice Address - Phone:610-775-3316
Practice Address - Fax:610-796-2962
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040616L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012539300007Medicaid
846509Medicare ID - Type UnspecifiedGROUP
516915Medicare ID - Type UnspecifiedINDIVIDUAL
PA0012539300007Medicaid